Sepsis recognition tools in acute ambulatory care: associations with process of care and clinical outcomes in a service evaluation of an Emergency Multidisciplinary Unit in Oxfordshire
Sepsis recognition tools in acute ambulatory care: associations with process of care and clinical outcomes in a service evaluation of an Emergency Multidisciplinary Unit in Oxfordshire
复制标题
DOI：
10.1136/bmjopen-2017-020497
复制
发表时间：
2018-04-01
期刊：
影响因子：
2.9
通讯作者：
Lasserson, Daniel S.
中科院分区：
文献类型：
--
作者：
Camm, Christian Fielder;Hayward, Gail;Lasserson, Daniel S.
目的评估现有的脓毒症识别工具在社区急性门诊病房患者中的表现。设计连续4个月的服务评估。建立社区急性门诊病房。对疑似感染患者的数据收集和结局观察、血液结果和预后数据进行分析。首次评估时的临床特征被用来填充脓毒症识别工具，包括：全身炎症反应综合征(SIRS)标准、国家早期预警评分(NEWS)、快速序贯器官衰竭评估(QSOFA)和国家卫生与护理卓越研究所(NICE)标准。根据升级护理的临床需求(使用静脉注射抗生素、液体、持续的门诊护理或医院治疗)和较差的临床结果(指数评估后30天的全因死亡率和再入院)对评分进行评估。结果在533名患者(中位年龄81岁)中，316名患者有疑似感染，其中120名患者需要超越简单的社区护理。对于是否需要升级护理，SIRS具有最高的阳性预测值(50.9%，95%CI 41.6%~60.3%)和阴性预测值(68.9%，95%CI 62.6%~75.3%)。对于疑似感染的患者，NEWS和SIRS都比QSOFA和NICE标准更能预测升级护理的需求(均为P<；0.001)。虽然新发病的混淆预示着85岁的患者(n=114)需要升级的感染护理，但23.7%的85岁的患者在没有感染证据的情况下有新的发病混淆。结论急性门诊护理临床医生在应用新的NICE认可的标准来确定是否需要静脉治疗和基于医院的护理地点时应谨慎行事。与NEWS和SIRS标准相比，NICE标准的表现较差，新发病的困惑在年龄=85岁且无感染的患者中普遍存在。
Objective To assess the performance of currently available sepsis recognition tools in patients referred to a community-based acute ambulatory care unit.Design Service evaluation of consecutive patients over a 4-month period.Setting Community-based acute ambulatory care unit.Data collection and outcomemeasures Observations, blood results and outcome data were analysed from patients with a suspected infection. Clinical features at first assessment were used to populate sepsis recognition tools including: systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA) and National Institute for Health and Care Excellence (NICE) criteria. Scores were assessed against the clinical need for escalated care (use of intravenous antibiotics, fluids, ongoing ambulatory care or hospital treatment) and poor clinical outcome (all-cause mortality and readmission at 30 days after index assessment).Results Of 533 patients (median age 81 years), 316 had suspected infection with 120 patients requiring care escalated beyond simple community care. SIRS had the highest positive predictive value (50.9%, 95% CI 41.6% to 60.3%) and negative predictive value (68.9%, 95% CI 62.6% to 75.3%) for the need for escalated care. Both NEWS and SIRS were better at predicting the need for escalated care than qSOFA and NICE criteria in patients with suspected infection (all P< 0.001). While new-onset confusion predicted the need for escalated care for infection in patients >= 85 years old (n=114), 23.7% of patients >= 85 years had new-onset confusion without evidence for infection.Conclusions Acute ambulatory care clinicians should use caution in applying the new NICE endorsed criteria for determining the need for intravenous therapy and hospital-based location of care. NICE criteria have poorer performance when compared against NEWS and SIRS and new-onset confusion was prevalent in patients aged >= 85 years without infection.